Treatment Services Application Renewal

OREGON YOUTH AUTHORITY Treatment Services

RENEWAL APPLICATION

SECTION I:Application Process and Instructions

SECTION II: Application Forms

Revised: 8/15 2. STATE OF OREGON 3. OREGON YOUTH AUTHORITY (OYA)

SECTION I: 4. CONTRACT RENEWAL APPLICATION 5. PROCESS AND INSTRUCTIONS

Purpose:

This renewal application is restricted to renewing services you are currently contracted to provide. All providers requesting to renew a current contract to provide therapy and/or sex offender treatment and/or alcohol and drug treatment services and/or psychological evaluation services are required to complete a Treatment Services Renewal Application.

Once a complete application is received in the Contracts Office and has been approved, a contract amendment will be developed and sent to you for signature.

If a renewal application is not received by the Contracts Unit by the date specified in the letter you received, the contract will expire and services will be terminated. If your contract expires, you will need to submit a full application packet to request a new contract.

No new or additional services can be requested through the renewal application. To add services, complete a new Community Treatment Services Application packet. When the solicitation is open, the application packet can be found on the Oregon Procurement Information Network (ORPIN) website at: http://orpin.oregon.gov/open.dll/welcome and the OYA website at: http://www.oregon.gov/OYA/contracts/shtml.

It is the OYA’s intent to continue contracting with each applicant who submits a complete renewal packet; meets the minimum qualifications; and meets the requirements as stated in this Application.

Referrals:

Per Section 2.D.iv of your contract, the OYA cannot predict the caseload for the future and does not guarantee any particular volume of business.

Instructions:

The following must be completed for all contract renewal applications:

. Application Cover Sheet (Form A)

. Fee-for-Service Rates (Form B)

 Proof of Insurance:

OYA requires insurance coverage in the amounts of $1,000,000 General Liability and $1,000,000 Professional Liability Insurance. This insurance is required for all providers of Community Treatment Services. A copy of your current insurance certificate is required with your renewal Application.

Treatment Services Renewal Application Page 2 of 11 Revised 8/15 . A list of all employees currently approved to provide services under your existing contract and which services they are providing (general therapy, sex offender treatment, alcohol and drug treatment, or psychology services).

. A list of staff to be removed from your contract because they are no longer providing services.

. For New Staff:

This renewal application is to renew services for staff that have been previously approved by the OYA. If you need to add additional staff, complete the Application for Additional Treatment Staff which can be found on the OYA website at: http://www.oregon.gov/OYA/contracts.shtml and attach it to this renewal Application.

The following must be provided for each individual who will be providing direct services to OYA youth under the renewal:

 Consent for Criminal Records Check (Form C)

 Provider Qualifications (Form D)

 Provide the license and/or certification number or copy of Current Professional License and/or Certification e.g. LCSW, LPC, Clinical Psychologist, CADC II, etc.

Agencies that are certified by OHA and have a DMAP number are permitted to have employees who have a Masters degree in a behavioral or social science (but do not have a mental health license) provide mental health and/or alcohol and drug treatment. The organization’s agency’s DMAP number(s) will be required.

The Contractor shall immediately notify the Oregon Youth Authority of any change in licensure, including any actions pending against a current license. OYA reserves the right to deny or terminate a contract if a certification/licensing board has imposed disciplinary action against a provider’s certification or license. OYA also reserves the right to deny or terminate a contract if negative action has occurred against a provider’s DMAP certification.

 Continuing Education:

Continuing education credits should reflect demonstrable education and training which allow the contractor to provide current, evidence-based/research informed practices for the services that are being provided. Continuing education is a critical part of maintaining professional standards in the practice of behavioral health treatment. OYA recognizes that licensure requires a certain number of CEUs to be completed and accepts current licensure as evidence that this training has occurred.

Providers who have unlicensed staff will be required to submit proof of ongoing training/education for those staff, with documentation reflecting that the training is relevant to adolescents and to the services being provided.

 Persons who provide sex offender treatment services for OYA youth must be have training and experience in risk assessments related to juvenile sex offending behavior, preferably the ERASOR, as part of the overall assessment and treatment process. You will need to provide documentation that you meet this standard.

Treatment Services Renewal Application Page 3 of 11 Revised 8/15 Depending on the type of risk assessment training you report, you may be required to attend the next scheduled risk assessment training provided by OYA.

 Persons who provide alcohol and drug treatment services for OYA youth must be receiving supervision in accordance with OAR 309-019-0125(4) and 0130(4)(b) and (c). You will need to provide documentation that you received supervision at least twice a month.

The following must be provided with the application:

 Signed Affidavit of Compliance with Tax Laws (Form E)

 Completed Checklist (Form F)

*Legislative changes are being discussed around provider credential requirements and may require us to change OYAs standards accordingly.

6. 7. Submit renewal application packet to:By Mail: 8. Oregon Youth Authority Attn: Contracts Unit 530 Center St. NE, Suite 200 Salem, Oregon 97301-3765 By Fax: 503-373-7921

Direct questions to: Laura Hince, Senior Contract Specialist (503) 373-7333 [email protected]

Incomplete Applications:

The provider is responsible for all information contained in this application. Please read all information and instructions carefully before submitting your application. Incomplete applications will be delayed, and may be disqualified or may be returned as incomplete.

Contractor Performance and Financial Responsibility:

Before renewing any contract, the OYA reserves the right to investigate previous performance and financial stability as these areas relate to the performance of the duties under any contract resulting from this application.

Applicants must successfully meet all requirements of this renewal application to continue contracting with the OYA. The Agency reserves the right to renew a contract based solely upon information submitted. The Agency may also choose to request additional information or to conduct interviews to provide clarification or answer questions the Agency may have in conjunction with the written responses to this request.

OYA is responsible for the care of the youth in its custody. At any point, the Agency may decide that an Applicant’s response to any one or more of the questions is sufficiently inadequate so as to disqualify the Applicant from providing care to the youth in OYA’s custody. The Agency reserves the right to withdraw, re-open, or otherwise amend the Renewal Application at any time, and to reject any or all applications, in whole or in part, when the Agency determines that it is in its best interest to do so.

Treatment Services Renewal Application Page 4 of 11 Revised 8/15 The following is a brief description of the services for each treatment area:

Treatment Services shall be provided to male and/or female youth offenders ages twelve (12) through twenty-four (24) years who have been committed to the OYA who are on parole from a youth correctional facility or are on probation and are possibly at risk of being placed in a more restrictive setting. These services may include, but are not limited to, individual, group, and/or family therapy; evaluations; and special assessments.

It is anticipated that the majority of services will be provided in a community setting. However, in consultation with the youth’s parole officer and/or transition specialist, and upon prior authorization by the contract administrator, services may be provided to youth offenders transitioning from close custody to a community placement. Contractors may be asked to meet with the youth offender at least once if the youth offender is in close custody in order to begin to establish a relationship. Contractors may be requested to travel to accommodate the treatment needs of the youth offender. Services for youth in transition must be initiated through the youth’s parole officer (JPPO).

Youth typically will present multiple treatment issues, which may include, but not be limited to:

Aggressive behaviors Mental health disorders as described in the most current version of the DSM Criminal behavior Multiple family losses Risky thinking patterns Prostitution Drug or alcohol affected infant Sexual offending (other than aftercare) Drug and alcohol issues Suicidal ideation or history of parasuicidal behavior Fire setting Abuse – Physical, Emotional, Neglect Grief and loss counseling Trauma Constructed coping skills/behaviors

In general, treatment services that are delivered to OYA youth offenders need to be focused on reducing recidivism and founded on modalities, techniques, and interventions known to be effective with the juvenile delinquent population. The majority of the therapeutic work done with OYA youth should be directed at increasing adaptive social skills along with creating and implementing effective relapse prevention planning.

General Therapy Services shall be provided to male and/or female youth offenders referred by the Agency who are on parole from a youth correctional facility or on probation and at risk of being placed in a more restrictive setting. These services may include but are not limited to, individual, group, and/or family therapy; special assessments and evaluations; consultations; and special reports.

Sex Offender Treatment Services shall be provided to male and/or female youth offenders referred by the Agency who are on parole from a state youth correctional facility or on probation and at risk of being placed in a more restrictive setting. These services are for paroled youth adjudicated of sex crimes and may include, but not limited to, individual, group and/or family therapy; special assessments and evaluations; consultations; and special reports.

Alcohol & Drug Treatment Services shall be provided to male and/or female youth offenders referred by the Agency who are on parole from a youth correctional facility or on probation and at risk of being placed in a more restrictive setting. These services may include but are not limited to, individual, group, and/or family therapy; special assessments and evaluations; consultations; special reports; and UA’s.

Treatment Services Renewal Application Page 5 of 11 Revised 8/15 Psychological Evaluation Services

Youth may present with developmental delays/deficits, impaired intellectual functioning, a history of trauma/abuse, aggressive behaviors, anti-social attitudes and beliefs, drug and alcohol issues, fire setting, grief/loss issues, immature coping skills/behaviors, multiple family losses, sexual boundary issues, sexual offending, suicidal/self harming behavior, victimization issues, domestic violence issues, and issues related to mental/behavioral health or other conditions that may or may not have been diagnosed.

The purpose of these services may be to diagnose and/or evaluate the youth, to make recommendations regarding treatment or other supportive services to address the issues affecting the youth’s ability to establish and maintain a productive, crime-free life. This may include making recommendations for services from other service agencies as determined appropriate based on the results of the evaluation.

Treatment Services Renewal Application Page 6 of 11 Revised 8/15 FORM A SECTION II: FORMS

9. STATE OF OREGON OREGON YOUTH AUTHORITY TREATMENT SERVICES RENEWAL APPLICATION COVER SHEET

10. The State of Oregon, acting by and through its Oregon Youth Authority (OYA), referred to herein as the Agency, issues this Renewal Application for Treatment Services to youth offenders.

1. Applicant’s Name (if applying as a business, use registered business name):

2. Primary Contact Person: Title:

3. Mailing Address: City, State, Zip:

4. Address where services will be provided (if different than mailing address):

City, State, Zip:

5. Telephone #: Fax#: 6. E-mail Address: 7. Name and title of the person(s) authorized to represent the Applicant in any negotiations and sign any Contract that may result:

Name: Title:

8. Currently providing the following services:

General Therapy

Sex Offender Treatment

Alcohol and Drug Treatment

Psychological Evaluation Services

9. Statement of acceptance of the terms and conditions contained in the Renewal Application: I hereby acknowledge and agree that I have read and understand all the terms and conditions contained in the Renewal Application.

I certify that the information I have provided is correct. I understand that any misrepresentations or incorrect information provided to OYA can result in disqualification of my application.

I hereby agree to use recyclable products to the maximum extent economically feasible in the performance of the work set forth in this Application . I have not and will not discriminate against a subcontractor in the awarding of a subcontract because the subcontractor is a minority, woman, or emerging small business enterprise certified under ORS 200.055.

Authorized Signature: Date: Treatment Services Renewal Application Page 7 of 11 Revised 8/15 Printed Name:

Treatment Services Renewal Application Page 8 of 11 Revised 8/15 FORM B FEE-FOR-SERVICE RATES The Agency shall not pay the Contractor for the shown to the right services at rates higher than those identified on the published OYA rate schedule, which can be found at http://www.oregon.gov/oya/Pages/contracts.aspx.

The Contractor agrees that the rates charged to the Agency for services to OYA youth shall not exceed the Contractor’s normal and customary rates for comparable services to the public. If your normal and customary rates for the services shown to the right below are LOWER THAN the published rates, please indicate those rates below.

Assessment – Psychology Services Only Psycho-diagnostic Interview by a psychologist or psychiatrist (without testing) (including report and interpretation) Hour I do not provide this service (2 hour $140.94 max) I accept the OYA published rate as shown to the right My usual and customary rate is lower than the OYA rate, use my rate for this service--$/hour Psychological Testing by a psychologist--testing (includes psycho-diagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS)

(including report and interpretation) Hour I do not provide this service (6 hour $91.19 max) I accept the OYA published rate as shown to the right

My usual and customary rate is lower than the OYA rate, use my rate for this service--$/hour

Neuropsychological Testing by a psychologist or psychiatrist (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test)

Psycho-diagnostic interview or psychological testing coded separately Hour I do not provide this service (3 hour $68.83 max) I accept the OYA published rate as shown to the right

My usual and customary rate is lower than the OYA rate, use my rate for this service--$_/hour

*NOTE: Neuropsychological Testing requires the pre-approval of the OYA Treatment Services Director in order to be paid under OYA contract Therapy—individual client or family Individual Therapy

I do not provide this service Hour $98.11 I accept the OYA published rate as shown to the right

Family Therapy

Group Therapy—multiple clients or families Group Therapy Hour $35.13

I do not provide this service I accept the OYA published rate as shown to the right

Treatment Services Renewal Application Page 9 of 11 Revised 8/15 Multifamily Treatment Group

Additional Services Consultation/Treatment Meetings

Special Assessments (Includes comprehensive mental health assessment, firesetter assessment, or sex offender assessment)

I do not provide this service Hour 8 hour $98.11 I accept the OYA published rate as shown to the right max) My usual and customary rate is lower than the OYA rate, use my rate for this service--$/hour

Note: ERASORs should be billed under this section Special Reports (i.e., court reports, special incident evaluations requiring new recommendations, referrals for other services)

Urinalysis

I do not provide this service Each $11.48 I accept the OYA published rate as shown to the right

Travel Mileage* (needs pre-approval from Contract Administrator)

I do not provide this service GSA Travel I accept the OYA published rate as shown to the right Mile Rates

My usual and customary rate is lower than the OYA rate, use my rate for this service--$/mile

I agree to be paid at the rates I have indicated above, or at OYA rates, whichever is lower.

Authorized Signature: Date:

Printed Name:

FORM C

State of Oregon YOUTH OFFENDER CONTRACTED PROVIDERS OREGON YOUTH AUTHORITY Treatment Services Renewal Application Page 10 of 11 Revised 8/15 CONSENT FOR CRIMINAL RECORDS CHECK

The mission of the Oregon Youth Authority (OYA) is to protect the public and reduce crime by holding youth offenders accountable and providing opportunities for reformation in safe environments. In keeping with these values, the OYA will conduct a criminal record check per OAR 416, Division 800. By your signature, you authorize OYA to obtain information about you from the Oregon State Police, the FBI and other law enforcement agencies, courts and record sources. Information obtained about an individual is confidential. An individual who refuses to consent to a criminal records/background check shall be disqualified from providing services.

Please PRINT all information clearly Name (last, first, middle):

Gender:

Treatment Services Renewal Application Page 11 of 11 Revised 8/15